Pain

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

This technical description of pain, recognizes both the physiologic and affective nature of the pain experience. Pain is a highly personal, subjective experience which can only be accurately described by the individual who is experiencing pain.
Recognition and acceptance of the subjectivity of pain are among the most challenging aspects of patient care; healthcare providers must intervene and treat patients on the basis of the self-report of the pain experience. In recent years, definitions of pain have been further refined to include the fact that a person's inability to verbally communicate does not preclude the possibility that pain is present or negate the responsibility of healthcare providers to treat it.

Definition
• Pain is an unpleasant sensor and emotional experience associated with actual or potential tissue damage or described in terms of such damage (IASP 2011)

Scope
• Pain is multidimensional having physical, psychological, social and spiritual aspects that all have to be addressed.
• This application only covers the pharmacological management of pain.
• The pharmacological management of pain is appropriate at all times including when active treatment aimed at cure or prolongation of life is being considered.
• Management of pain should not be deferred until the underlying cause of the pain has been identified, but identification and if appropriate, treatment of the underlying cause should be undertaken simultaneously.

Analgesics in the management of pain in palliative care
IBUPROFEN
• It is a nonsteroidal anti-inflammatory drug (NSAID) used for pain relief, fever reduction, and swelling.
• It has an antiplatelet effect, though relatively mild and somewhat short-lived compared with aspirin or prescription antiplatelet drugs. It also acts as a vasoconstrictor.

MORPHINE
• It is widely accepted as the strong opioid of choice in moderate to severe pain.
• It is the most abundant alkaloid found in opium, the dried latex extracted by shallowly slicing the unripe seedpods of the Papaver somniferum poppy.
• It is the prototype narcotic drug and is the standard against which all other opioids are tested. It has proven efficacy as an analgesic and has an important role in the management of moderate to severe pain in palliative care.
• It is a phenanthrene opioid receptor agonist – its main effect is binding to and activating the μ-opioid receptors in the central nervous system. In clinical settings, morphine exerts its principal pharmacological effect on the central nervous system and gastrointestinal tract.
• Activation of the μ-opioid receptors is associated with analgesia, sedation, euphoria, physical dependence, and respiratory depression.
• The effects of morphine can be countered with opioid antagonists such as naloxone and naltrexone.
• Other opioids such as hydromorphone or oxycodone can be used as alternatives for treatment of pain in palliative care. No advantage of any opioid has been described in the systematic reviews.
• Morphine is the most widely available strong opioid and given its proven efficacy, its use is recommended in moderate to severe pain in palliative care.
• Morphine is available in wide range of application forms. Costs are low for oral application forms such as tablets or solution

Recommendations
• Non-steroidal anti-inflammatory drugs (NSAIDs) have theoretical advantage in bone or soft tissue pain due to their peripheral anti-inflammatory effect. Their efficacy in reducing pain and opioid doses has been demonstrated although not specifically in patients with bony metastases or mucositis.
• Inclusion of ibuprofen as an analgesic for management of mild pain in palliative care
• Inclusion of morphine as a strong analgesic for management of moderate to severe pain in palliative care
• Opioids in many countries of the world are underutilized often due to lack of knowledge and skills needed to properly evaluate, assess and treat pain and the fear of physicians, patients and their families of opioid addiction and tolerance. Additionally, strict regulations and control of these agents in many countries create difficulties in the prescription and dispensing processes.

Adapted from Radbruch L et al. Essential medicines in palliative care - An application for the 19th WHO Expert committee on the selection and use of essential medicines. Kindle Edition, 135 pages. Published June 5th 2013 by IAHPC Press. Available at https://www.amazon.com/Essential-Medicines-Palliative-Care-Application-ebook/dp/B00D7S2D0C

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